Pain: Healthcare's Persistent ChallengePage 19 of 21

17. Barriers to Effective Pain Management

The [Institute of Medicine] committee [has] identified several important barriers to adequate pain care in the United States. These include the magnitude of the problem, provider attitudes and training, insurance coverage, cultural attitudes of patients, geographic barriers, and regulatory barriers.

Institute of Medicine, 2011

Consider the following barriers to effective pain management.

Where are the tools and the time, and how am reimbursed? Those are the issues and barriers in pain management. Given the time constraints in an office setting, how can I improve my expertise and how can I be reimbursed? Regardless of the type of pain, it’s fair to say that anyone who has chronic, prolonged pain is going to have psychological issues that must be addressed. Where you see a patient on the continuum of their pain is going to influence the provider and what sort of treatment modalities you offer.

We are being slammed with all these new position papers and regulations about abuse of opioids saying “Hey, you guys, this is all your fault and you should have been doing more”—even though the insurance companies aren’t providing more reimbursement, nor is anyone providing practical tools to enhance provider training, skills, and all those things. For liability purpose the focus is going to shift onto the provider and that’s going to make us reluctant to prescribe. The onus is on the prescriber not to prescribe. Treating pain properly and effectively is an order of magnitude more complicated than it used to be because of these issues and barriers.

Board Certified Family Nurse Practitioner, California

The complexity of our healthcare system creates significant barriers to effective pain management in all areas of medicine and across all age groups. The sheer magnitude and complexity of treating pain in a fragmented healthcare system that is struggling to contain costs means better education and training, better interdisciplinary communication and cooperation, and better reimbursement for proven treatment options are desperately needed.

According to the Institute of Medicine, treatment of pain is often disorganized, ineffective, and inaccessible. Many members of the public, people with pain themselves, and many health professionals are not adequately prepared to take preventive action, recognize warning signs, initiate timely and appropriate treatment, or seek specialty consultation when necessary with respect to pain (IOM, 2011).

Several factors influence treatment options, especially when pain is persistent or severe (PPSG, 2014b):

  1. Knowledge, beliefs, and attitudes of healthcare professionals
  2. Patient and family perceptions
  3. Inadequate attention to pain in certain patient populations
  4. Restrictive policies governing healthcare practice, as well as concerns about regulatory scrutiny when prescribing controlled substances

Costly, inappropriate, or inadequate procedures are sometimes carried out when other approaches—such as counseling, prevention, and self-management—might be more appropriate. There is still variability among clinicians in applying new and even existing knowledge about pain and its management. This is reflected in the documentation of inappropriate or indeed lack of treatment for cancer patients, HIV/AIDS patients, and neonates—and post operative pain, among others (Sessle, 2012).

To address these issues and barriers, the Institute of Medicine (IOM, 2011) has recommended:

  • Providers should promote and enable self-management of pain.
  • There should be easily accessible and cost-effective educational opportunities in pain assessment and treatment in primary care.
  • Collaboration must be improved between pain specialists and primary care clinicians, including referral to pain centers when appropriate.
  • Reimbursement policies must be revised to foster coordinated and evidence-based pain care.
  • Providers must provide consistent and complete pain assessments.

Education. Education. Education. Educate more physicians on proper diagnosis and proper pain management. Educate the person living with pain and their family on addiction versus physical dependency and proper storage of medication. Educate the public and press about the realities of pain medication and people living with pain.

Person with Chronic Pain, IOM, 2011

The inadequate education of healthcare professionals is a major and persistent barrier to effective pain management. Despite the health professions’ development of competencies in pain management, as well as the myriad guidelines and position articles on pain management issued by numerous professional bodies, core pain management competencies for pre-licensure, entry-level health professionals have not yet been established. The limited pain education that is currently provided may be ineffective because it focuses on traditional, impersonal topics such as anatomy and physiology that may have little direct relevance to the complex daily problems faced by patients, families, and clinicians (Fishman et al., 2013).

In most health professional programs, the topic of pain occupies only a minor component of the curriculum. In North America and Europe, for example, dental and medical students receive on average less than 20 hours of formal education about pain throughout their multi-year program. The Institute of Medicine has stated that pain education is critically important and that the federal government is in a position to contribute to improvements in patient and professional education about pain. The IOM recommends that the medical professionals (1) expand and redesign education programs, (2) improve curriculum and education for healthcare professionals, and (3) increase the number of health professionals with advanced expertise in pain care (IOM, 2011).

The American Academy of Pain Medicine has echoed the IOM recommendations by publishing a set of inter-professional core competencies for pain management, which are categorized within four domains. These domains address (1) the fundamental concepts and complexity of pain; (2) how pain is observed and assessed; (3) collaborative approaches to treatment options; and (4) application of competencies across the lifespan in the context of various settings, populations, and care team models (Fishman et al., 2013).

Undergraduate health science programs can play a role in improving our understanding of pain and its management. Currently, most undergraduate healthcare programs provide limited pain content, which does not ensure that graduates have the knowledge, skills, or clinical competence to provide quality pain care throughout the lifespan. Understanding the phenomenon of pain, its immediate and long-term consequences, and its effective management is lacking or is minimal in many health science curricula, including those for nursing. This lack of knowledge and effective translation into a usable form for practitioners raises the following question: Do graduates have sufficient knowledge and skills to be competent in giving appropriate pain management to their patients (Herr et al., 2015)?

Core competencies in pain management for pre-licensure health professional education have been established, which map well to the International Association for the Study of Pain’s inter-professional pain curricula. These competencies delineate expectations for minimally acceptable skills for pain management for graduating health profession students, regardless of discipline. They provide a basis for preparing students to apply knowledge and skills successfully in a manner that supports inter-professional team contributions in providing quality pain care in the real world (Herr et al., 2015).